Defining a Pathway for Health Everychild Foundation

State of Our Children: LA 2013 Symposium

January 23, 2013

Jonathan E. Fielding, MD, MPH, MBA

Director and Health Officer

Los Angeles County Department of Public Health

Distinguished Professor of Health Services and Pediatrics

Schools of Public Health and Medicine, UCLA

1

4,060 square miles

88 incorporated cities

2 islands

9.8 million residents (more than 41 States)

100+ languages spoken by significant size populations*

16% of entire population living in poverty

23% of children in poverty**

US Census Bureau: State and County QuickFacts, last revised Nov 2010; * July 1, 2008 Population and Poverty

Estimates, prepared by Walter R. McDonald & Associates, Inc. for Urban Research;** 2011 KIDS COUNT Data Book,

Annie E. Casey Foundation.

Los Angeles County: Background

2

Age Total

Population

MALE

% of Total

Population

FEMALE

% of Total

Population

LA

County 9,889,056 4,877,989 5,011,067

0-4 6.6% 6.8% 6.3%

5-9 6.3% 6.6% 6.0%

10-14 6.8% 7.0% 6.6%

15-19 7.4% 7.7% 7.1%

Total 27.1% 28.1% 26.0%

Source: American Fact Finder: Age and Sex: 2011 American Community Survey 1-Year Estimates

http://factfinder2.census.gov/faces/tableservices/jsf/pages/productview.xhtml?pid=ACS_11_1YR_S0101&prodType=table

MORE THAN A

QUARTER

OF THE

COUNTY’S

POPULATION

2.6 Million+

Children, Adolescents & Young

Adults in LA County, 2011

3

Age group

# of deaths

Age-specific

death rate

#1 cause

#of deaths

Age-specific

death rate

#2 cause

# of deaths

Age-specific

death rate

#3 cause

# of deaths

Age-specific

death rate

#4 cause

# of deaths

Age-specific

death rate

#5 cause

# of deaths

Age-specific

death rate

<1 year old

741

488 per 100,000

Low BW/

prematurity

116

76 per 100,000

SIDS*

63

41 per 100,000

Heart defect

42

28 per 100,000

Pregnancy

complication

29

19 per 100,000

Other birth

defects

27

18 per 100,000

1-4 years old

111

18 per 100,000

MV crash**

16

Homicide**

15

Birth defect**

13

Brain/CNS

cancer**

7

Septicemia**

<5

5-14

208

14 per 100,000

Homicide

28

2 per 100,000

MV crash

26

2 per 100,000

Birth defect

20

1 per 100,000

Brain/CNS

cancer**

18

Leukemia**

13

15-24

932

60 per 100,000

Homicide

322

21 per 100,000

MV crash

196

13 per 100,000

Suicide

90

6 per 100,000

Drug OD

41

3 per 100,000

Leukemia

24

2 per 100,000

Source: Mortality in Los Angeles County 2008 Leading Causes of Death and Premature Death With Trends

for 1999 2008. Accessed at http://publichealth.lacounty.gov/docs/mortality2008-dec2011.pdf * Sudden Infant Death Syndrome.

** # of deaths too small to calculate a reliable rate.

MANY CAUSES

ARE

PREVENTABLE!

Leading Causes of Death

Ages 0-24, 2008

4

• In LA County, life expectancy for an African

American male at birth (69.4 yrs) is nearly 18 years

shorter than that of an Asian/Pacific Islander female

(86.9yrs)

5 Los Angeles County Department of Public Health. Life Expectancy in Los Angeles County: How Long Do We Live and Why?

July 2010.

Disparities Persist

6

8.1%6.4%

18.4%

6.7%

0%

2%

4%

6%

8%

10%

12%

14%

16%

18%

20%

White Latino Black Asian/PI

Source: LAC Health Survey: Childhood Asthma, 2007, LACDPH

Asthma: Lifetime Prevalence in Children by

Race/Ethnicity, LA County, 2007

Lu MC, Halfon N. Racial and ethnic disparities in birth outcomes: a life-course perspective.

Maternal Child Health J. 2003;7:13-30.

Protective &Risk

Factors

• Socioeconomic status

• Race and racism

• Health care

• Disease status

• Stress

• Nutrition

• Weight status

• Birth weight

• Various health

behaviors

Disparities from the Life Course Perspective

7

• Intergenerational impact of pregnancies on major

chronic diseases

• Mother’s body composition and diet at conception and

during gestation have important effects on health of

offspring

• The lower the weight at birth and during infancy the

higher the risk for coronary heart disease later in life

• Low birth weight also associated with increased risk of

hypertension, stroke and type 2 diabetes

Intergenerational Health Effects

8 http://www.thebarkertheory.org/index.php

9

• Preconception – Maintain healthy weight

– Folic acid supplementation

• Prenatal – Early care

– Healthy weight gain

– Disease screening (e.g. Diabetes)

• Maternal obesity in early pregnancy more than doubles risk of obesity in child 2-4 years old¹

1. Whitaker, R.C. Predicting Preschooler Obesity at Birth: The Role of Maternal Obesity in Early Pregnancy.

Pediatrics 2004. 114:e29-e36.

Prevention Before Day One

10

Prevalence of Pre-Pregnancy Obesity or Overweight Among

Women Who Recently Had a Live Birth, by Age and

Race/Ethnicity, LA County, 2010

African

American

Asian/PI

Los Angeles County Department of Public Health

Maternal, Child and Adolescent Health Programs

Los Angeles Mommy and Baby Project

11

Best health outcomes are associated with:

• exclusive breastfeeding

• sustained breastfeeding

Breastfeeding = Optimal Infant Nutrition

-23%

-42%

-64%

-40% -39%

-19%

-36%

-24%

-70%

-60%

-50%

-40%

-30%

-20%

-10%

0%

Ip S, Breastfeeding and maternal and infant health outcomes in developed countries. Rockville, MD: U.S. Dept. of

Health and Human Services, Public Health Service, Agency for Healthcare Research and Quality; 2007.

Acute Chronic

Breastfeeding – Prevention for Babies

Risk Differences for Various Diseases

13

A Critical Time for Brain Development

Source: Dr. Jack P. Shonkoff

Center on the Developing Child, Harvard University

Middle

Childhood

(6 – 12 Yrs)

Develop skills for

building healthy

social relationships

and learn roles that

lay groundwork for

a lifetime

Adolescent

(10 – 19 Yrs)

Establish behavioral patterns

that help determine current

health status and risk for

developing chronic diseases

in adulthood

14

Healthy People 2020: Developmental Periods

Early

Childhood

(Birth – 8 Yrs)

Tremendous

physical,

cognitive and

socio-emotional

development

http://www.healthypeople.gov/2020/topicsobjectives2020/overview.aspx?topicid=10

• Surveyed over 9,500 adults

• 7 categories of adverse childhood experiences:

– Psychological, physical or sexual abuse; violence

against mother; or living with household members

who were substance abusers, mentally ill, suicidal

or ever imprisoned.

• Strong graded relationship between ACEs and multiple risk factors for

several leading causes of death including cancer, chronic lung disease,

and liver disease.

• Later ACE study2 (n=17,000+ adults) associated ACEs with increased

risk of premature death.

– People with 6+ ACEs died nearly 20 years earlier, and had 3x times greater years

life lost per death, than those without ACEs.

15 1) Felitti VJ, et al. Relationship of childhood abuse and household dysfunction to the many of the leading causes

of death in adults: the Adverse Childhood Experiences (ACE) Study. Am J Prev Med 1998 May; 14(4):245-58.;

2) Brown DW, et al. Adverse childhood experiences and the risk of premature mortality. Am J Prev Med 2009 Nov; 37(5):389-96.

Adverse Childhood Experiences (ACE) Study1

5 10 15 20 30 40 50 60 70 80

Age (years)

Relative

magnitude

of influence

Adapted from Nordio S. 1978. Needs in Child and Maternal Care. Rational utilization and Social Medical resources.

Riviests Italiana de Pediatria 4:3-20. As cited in Halfton, N., M Hochstein. 2000. The Health Development Organization:

An Organizational Approach to Achieving Child Health Development, The Milbank Quarterly 78(3):447-497.

Health Influences Over the Lifetime

16

One Model of Population Health

Health Factors

Health

Outcomes

Programs and

Policies

Mortality (50%)

Morbidity (50%)

Physical environment

(10%)

Social & economic

factors (40%)

Health behaviors

(30%)

Clinical care

(20%)

Unsafe sex

Alcohol use

Diet & exercise

Tobacco use

Access to care

Quality of care

Community safety

Education

Family & social support

Employment

Income

Built environment

Environmental quality

County Health Rankings model © 2010 UWPHI

17

Improving Educational Outcomes

Improves

Health Outcomes

18

47.9

53.450.6

56.452.2

57.454.758.5

0

10

20

30

40

50

60

70

Men Women

Life

exp

ecta

ncy

at

age

25

0-11 yrs

12 years

13-15 years

16 or more years

Years of School Completed

Robert Wood Johnson Foundation. Overcoming Obstacles to Health: Report from the Robert

Wood Johnson Foundation to the Commission to Build a Healthier America. February 2008.

Education Matters:

More Formal Education = Longer Life Expectancy

19

8.17.6

6.2

4.2

0

1

2

3

4

5

6

7

8

9In

fan

t M

ort

ali

ty R

ate

s

(pe

r 1

,00

0 l

ive

bir

ths

)

0-11 years

12 years

12-15 years

16 or more years

Years of School Completed by

Mother, All Ages

Robert Wood Johnson Foundation. Overcoming Obstacles to Health: Report from the Robert

Wood Johnson Foundation to the Commission to Build a Healthier America. February 2008.

And It Matters to the Next Generation:

Mother’s Education Related to Infant Mortality

20

21 U.S. Census Bureau, Small Area Income and Poverty Estimates Program, November 2011

Accessed at: http://www.census.gov/did/www/saipe/data/interactive/

Poverty US, CA, LA County: Under Age 18

NEARLY 1 IN 4

CHILDREN IN

LA COUNTY

LIVE BELOW

FPL

• How much income does

a family need to meet

basic needs without

public or private aid in

LA County?

• Self-sufficiency standard

is based on the costs

families face daily

– Housing, food, child care,

out-of-pocket medical

expenses, transportation,

and other necessary

spending

22 Insight Center for Community Economic Development.

Accessed at http://www.insightcced.org/communities/cfess/ca-sssold/SSS-Los-Angeles-12.html

Family Economic Self-Sufficiency Standard:

LA County, 2011

• Children born poor are 3x more likely not to complete HS than those not

born poor.1

• By age 50, children who grew up in poverty are more likely to have

asthma, hypertension, diabetes, stroke,

heart attack and heart disease than

children who did not.2

• Studies have shown lower-income

children experience higher rates of

asthma, heart conditions, hearing

problems, digestive disorders,

elevated blood lead levels and

are more likely to be obese.3, 4, 5

Some Effects of Poverty

23 1) Ratcliffe C. et al. Childhood Poverty Persistence: Facts & Consequences. The Urban Institute, Brief 14, June 2010; 2) Johnson R, et al. Early-life Origins of Adult

Disease: National Longitudinal Population Based Study of the United States. Am J Public Health. 2011 Dec; 101(12):2317-2324; 3) RWJF. Exploring the Social

Determinants of Health: Income, Wealth & Health. Issue Brief, April 2011; 4) Case A. et al. Economic Status and Health in Childhood: The Origins of the Gradient.

American Economic Review 2002;92:1308-1334; 5) Pamuk E. Socioeconomic Status & Health Chartbook. 1998 Hyattsville, MD:Natl Center for Health Statistics; 1998.

Bottom 10*

City/Community Name

Obesity

Prevalence

(%)

Rank of

Economic

Hardship

(1 - 128)

West Athens 30.6 94

South Gate 30.7 110

Florence-Graham 31.0 128

West Whittier-Los Nietos 31.1 81

West Carson 31.4 56

Vincent 32.2 69

East Los Angeles 32.9 117

Hawaiian Gardens 33.4 107

South El Monte 34.5 111

Walnut Park 38.7 113

Average 10 highest 32.7%

Ave Median Household Income $37,747

Top 10*

City/Community

Name

Obesity

Prevalence

(%)

Rank of

Economic

Hardship

(1 - 128)

Manhattan Beach 3.4 2

Calabasas 5.0 8

Hermosa Beach 5.1 1

Agoura Hills 5.3 10

Beverly Hills 5.4 19

Malibu 5.9 4

Palos Verdes Estates 7.3 5

San Marino 7.8 15

Rolling Hills Estate 8.4 9

La Canada Flintridge 8.5 18

Average 10 lowest 6.2%

Ave Median Household Income $99,555

*Table excludes cities/communities where number of students with BMI data < 500. Source: CA Physical Fitness Testing Program, CA Department of Education. Includes 5th, 7th, and 9th graders enrolled in LAC public schools; 2000 Census

Cities/Communities with Lowest and Highest

Childhood Obesity Prevalence, 2008

“Healthy development in the early years

provides the building blocks for educational

achievement, economic productivity,

responsible citizenship, lifelong health, strong

communities and successful parenting of the

next generation.” - Dr. Jack P. Shonkoff

Director, Center on the Developing Child

Harvard University

25

A Successful Society’s Foundation

is Built in Early Childhood

• Children and adolescent health, safety and well-being

are affected by an interplay of factors

- e.g. between the individual and their parents, peers, schools, health

care systems, media and policies and laws in many sectors

• Improving health requires government agencies,

community organizations, schools, businesses and

other stakeholders to work together with an eye toward

creating healthy communities and environments for our

youngest residents

26

Call to Action

Policies can improve physical and social environments

• Create safe places for physical

activity

– Joint use agreements

– Walkable/bikable community design

– Pocket park development

• Improve access to early childhood development

programs, particularly for low-income children

27

Policies As Levers of Change

Top Photo Credit: LAUP - Yoga Class

• Fund youth apprenticeship programs and vocational training for

at-risk youth

• Expand tenant based rental assistance programs

• Find permanent housing solutions for homeless individuals and

families

• Strengthen programs that effectively teach parenting skills

• Ensure all eligible families receive economic supportive services

– Supplemental Nutrition Assistance Program

– Earned Income Tax Credit

28

Photo Credit: Ruby Washington, New York Times

Policies As Levers of Change (continued)

Policies can increase protective factors

– Support community efforts to

build social connectedness

(e.g. community gardens)

– Address potentially harmful

environmental exposures

(e.g. siting schools away from

freeways to reduce asthma burden)

– Create environments geared toward prevention (e.g. baby-

friendly hospitals)

29

Policies As Levers of Change (continued)

Photo credit: Cade Martin, CDC

30

Thank You! Thank You!

Jonathan E. Fielding, MD, MPH, MBA

Director and Health Officer

Los Angeles County Department of Public Health

Distinguished Professor of Health Services and Pediatrics

Schools of Public Health and Medicine, UCLA